Important Differences in Mode of Death Between Men and Women With Heart Failure Who Would Qualify for a Primary Prevention Implantable Cardioverter-Defibrillator

Study Questions:

Do differences between men and women exist for mode of death among heart failure patients who meet criteria for a primary prevention implantable cardioverter-defibrillator (ICD)?

Methods:

Data from five trials or registries were used for the present analysis. Subjects were included if they were ambulatory heart failure patients with predominately systolic left ventricular dysfunction who were candidates for a primary prevention ICD (New York Heart Association [NYHA] class II–III and left ventricular ejection fraction 35%). The registries/trials included were the Prospective Randomized Amlodipine Survival Evaluation (PRAISE); the University of Washington Medical Center heart failure cohort; the Valsartan Heart Failure Trial (Val-HeFT); the Carvedilol Or Metoprolol European Trial (COMET); and the Italian Heart Failure Registry (IN-CHF). The primary outcome was sex-related differences in total deaths and total deaths by mode of death. The Seattle Heart Failure model was used to estimate total mortality in this analysis.

Results:

Of 10,038 patients evaluated for inclusion into the study, 55 patients (5.5%) with NYHA class I or IV heart failure symptoms, 1,084 (10.8%) patients with left ventricular ejection fraction <35%, 130 (1.3%) patients who received a heart transplant, and 30 (0.3%) patients who had an ICD at baseline were excluded, leaving 8,337 patients eligible for analysis, of which 1,685 (20%) were women. Women were older and were less likely to have ischemic heart disease. Total mortality for all patients over a median follow-up period of 2.4 years was 26.3%. Overall, 10.5% of patients died suddenly (40% of all deaths), 7.9% died of pump failure (30% of all deaths), and 7.9% of patients died in other ways (30% of all deaths). Overall 1-year mortality for all-cause mortality was 10.8% ± 0.3%, of which 5.3 ± 0.3% died suddenly, 3.1 ± 0.2% died of pump failure, and 2.8 ± 0.2% had other causes of death. Age-adjusted all-cause mortality was 24% lower for women than for men (hazard ratio [HR], 0.76; 95% confidence interval [CI], 0.68-0.85; p < 0.0001). Age-adjusted mortality from sudden death was 31% lower for women compared with men (HR, 0.69; CI, 0.58-0.83; p < 0.0001). Mortality from pump failure was similar in men and women (HR, 0.95; CI, 0.78-1.14; p < 0.56). Mortality from other causes was 27% lower in women (HR, 0.73; CI, 0.60-0.90; p < 0.003).

Conclusions:

The authors concluded that women with heart failure have a lower mortality rate than men. Death rates were lower throughout a range of mortality risk.

Perspective:

These data suggest gender-related differences in outcomes among patients with heart failure. Further sex-specific research is warranted to understand such differences in the progression and management of heart failure.

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Important Differences in Mode of Death Between Men and Women With Heart Failure Who Would Qualify for a Primary Prevention Implantable Cardioverter-Defibrillator